Provider Demographics
NPI:1437146230
Name:DULLYE, TARA A (MD)
Entity Type:Individual
Prefix:DR
First Name:TARA
Middle Name:A
Last Name:DULLYE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 961205
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76161-1205
Mailing Address - Country:US
Mailing Address - Phone:817-740-8450
Mailing Address - Fax:
Practice Address - Street 1:8160 WALNUT HILL LN STE 219
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4354
Practice Address - Country:US
Practice Address - Phone:214-369-2400
Practice Address - Fax:214-369-7528
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-05
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK4327207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1693467Medicaid
TX8D1725Medicare ID - Type Unspecified
TX1693467Medicaid